NAT IONA L DRUG CON T ROL S T R AT EGY 2015 Table of Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Chapter 1: Strengthen Efforts to Prevent Drug Use in Our Communities . . . . . . . . . . . 11 Chapter 2: Seek Early Intervention Opportunities in Health Care . . . . . . . . . . . . . . 23 Chapter 3: Increasing Access to Treatment and Supporting Long-Term Recovery . . . . . . . 29 Chapter 4: Criminal Justice Reform: Making the System More Effective and Fair . . . . . . . . 41 Chapter 5: Disrupt Domestic Drug Trafficking and Production . . . . . . . . . . . . . . 53 Chapter 6: Strengthen Law Enforcement and International Partnerships to Reduce the Availability of Foreign-Produced Drugs in the United States . . . . . . . . . . . . . . . 65 Chapter 7: Improve Information Systems for Analysis, Assessment, and Local Management . . . 79 Policy Focus: Preventing and Addressing Prescription Drug Misuse and Heroin Use . . . . . . 87 Policy Focus: Drugged Driving . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 ★ i ★ To the Congress of the United States: I am pleased to transmit the 2015 National Drug Control Strategy, my Administration’s 21st century approach to drug policy that works to reduce illicit drug use and its consequences in the United States. This evidence-based plan, which balances public health and public safety efforts to prevent, treat, and provide recovery from the disease of addiction, seeks to build a healthier, safer, and more prosperous country. Since the release of my Administration’s inaugural National Drug Control Strategy in 2010, we have seen significant progress in addressing challenges we face along the entire spectrum of drug policy—including prevention, early intervention, treatment, recovery support, criminal justice reform, law enforcement, and international cooperation. However, we still face serious drug-related challenges. Illicit drug use is a public health issue that jeopardizes not only our well-being, but also the progress we have made in strengthening our economy—contribut- ing to addiction, disease, lower student academic performance, crime, unemployment, and lost productivity. Therefore, we continue to pursue a drug policy that is effective, compassionate, and just. We are working to erase the stigma of addiction, ensuring treatment and a path to recovery for those with substance use disorders. We continue to research the health risks of drug use to encour- age healthy behaviors, particularly among young people. We are reforming our criminal justice system, providing alternatives to incarceration for non-violent, substance-involved offenders, improving re-entry programs, and addressing unfair sentencing disparities. We continue to devote significant law enforcement resources to reduce the supply of drugs via sea, air, and land interdiction, and law enforcement operations and investigations. We also continue to partner with our international allies, helping them address transnational organized crime, while ad- dressing substance use disorders and other public health issues. I thank the Congress for its continued support of our efforts. I look forward to joining with them and all our local, State, tribal, national and international partners to advance this impor- tant undertaking. President Barack Obama The White House ★ iii ★ Preface from Director Botticelli The 2015 National Drug Control Strategy continues our dynamic, reform-oriented approach to drug policy, and reflects our desire to continuously seek out individuals who will help improve and refine our efforts. As I traveled the country as a part of our consultation process, I went to Boston for a roundtable discussion with some of the most influential names in the substance use disorder field. While stopping for coffee, I happened to meet Melissa, who told me her story. Melissa started misusing pain medication after being prescribed OxyContin for a back injury. For a while, she was able to take it as directed. But she eventually started misusing her medica- tion, developed a serious substance use disorder, and began using heroin. Eventually, Melissa lost her apartment and became homeless. She knew she needed help, so she turned to a local clinic that provides substance use disorder services, including medication-assisted treatment (MAT), for the homeless. Fortunately, Melissa lives in a state where she qualified for Med- icaid coverage and which supports all the Food and Drug Administration (FDA)-approved medications for opioid use disorders. She was also tested at the clinic for infectious diseases associated with injection drug use. We are thankful that Melissa does not have viral hepatitis or HIV. She still lives in a shelter for homeless women, but she is on the path to recovery. Not long ago, she landed a job at that same coffee shop. She is well on her way to getting back to life without drugs. I met Michael at a recovery celebration at the White House. Michael was born in Compton, California. He was a bright teenager, and his mom did her best, but the circumstances he was born into prevailed and he got involved with a gang in high school. He dropped out. He de- veloped a substance use disorder involving crack cocaine, and found himself homeless, alone, and in despair. In 1996, he was arrested and convicted for possession of less than a gram of crack. Under California’s Three Strikes Law, he was sentenced to 25 years in prison. In prison, he began to study in the prison law library and spent his time appealing his sentence. In 2002, six years after his conviction, his appeal went to the U.S. District Court, where a judge, after re- viewing his case for two and a half years, overturned the sentence and freed Michael. Since his release, Michael has spent his time mentoring others in recovery and working to prevent teens in Compton from joining gangs or using drugs. He earned his GED, and now he is enrolled in college and working full-time. Hearing from Melissa and Michael, and countless other Americans reaffirms my belief in the importance of our work and the role public policy can play in helping to improve lives. While we continue to pursue the goals set by the President’s inaugural National Drug Control Strategy, we remain mindful of the people the Strategy seeks to serve. I look forward to working with the Congress and the American people throughout the next year to implement the Strategy and reduce illicit drug use and its consequences. Michael P. Botticelli Director of National Drug Control Policy ★ v ★ Introduction Throughout much of the last century, our understanding of drug use was influenced by powerful myths and misconceptions about the nature of addiction . People who used illicit drugs and had substance use disorders were thought to be morally flawed or lacking in willpower . These views shaped our responses to drug policy, resulting in punitive rather than therapeutic approaches to reduce drug use . Today, the Nation’s response to addressing substance use disorders and our views about those who suffer from the disease of addiction have begun to change . Groundbreaking discoveries about the brain have revolutionized our understanding, therefore enabling us to develop evidence-based and humane interventions to reduce drug use and its consequences . Substance use disrupts our families, schools, and communities and limits the hopes and dreams of young people across the country . Illicit drug use is associated with addiction, disease, and lower academic performance among our young people, and contributes to crime, injury, lost productivity and serious dangers on our Nation’s roadways . Successfully addressing these complex issues requires a range of approaches . The Obama Administration is committed to restoring balance to U .S . drug-control efforts by coordinating an unprecedented government-wide public health and public safety approach . The Administration’s goal is to make sure services for substance use disorders remain a priority . We are focusing on improving access to services and treatment across the continuum of care, from prevention and intervention to treatment and recovery . We know how to effectively prevent youth substance use, we have treatment interventions that work, including MAT for alcohol and opioid use disorders, and we know how to sustain recovery . The Patient Protection and Affordable Care Act (ACA) enables mil- lions more people to have access to health care and treatment for their conditions . The ACA presents tremendous opportunities to reform drug policy . But to fulfill this promise, we must make sure that substance use disorder treatment is truly integrated into mainstream health care, and that the millions currently without access to necessary treatment for the disease of addiction get the care they need and are aided in their recovery . Substance use disorders are medical conditions, and reducing stigma surrounding these medical condi- tions is a particularly important component of drug policy reform—one in which every American can play a part . As we have worked to help millions of people into recovery and support the millions more who are already in long-term recovery, we have learned that how we describe or refer to people with substance use disorders can have an important effect on outcomes . Research demonstrates that the use of stigmatizing words like “addict” can: • Discourage individuals from seeking help .1 • Reinforce the idea that someone with a substance use disorder is exhibiting a willful choice rather than suffering from a recognized medical condition .2 • Evoke less sympathy than if the individual is described as having a disease .3 Avoiding these terms, thereby reducing the stigma, can play an important role in encouraging these individuals to seek help at an earlier stage in the disease . ★ 1 ★ naTIonal DrUg ConTrol STraTegy In terms of prevention, there is much more we can do to keep young people from ever initiating drug or alcohol use . There are many evidence-based prevention efforts but they are underutilized—they must exist in our schools, our communities and in our homes . Prevention is critical because the most cost effective way to deal with drug and alcohol use and substance use disorders is to prevent them from occurring in the first place . The Nation has seen remarkable success in preventing young people from smoking cigarettes . The prevalence of past 30 day cigarette use among 8th, 10th and 12th graders, as measured by the 2014 Monitoring the Future (MTF) study, are at their lowest levels ever recorded by the survey .4 MTF also demonstrates significant reductions over the past five years in the rates of alco- hol use in all grades and a significant drop in binge drinking among high school seniors, which is now under twenty percent . Still, nearly 1 in 5 high school seniors report binge drinking within the past two weeks . We can continue to reduce the rates of substance use through implementing evidence-based prevention programs that promote positive messages and advise young people of associated risks and consequences . The Administration is also committed to criminal justice reform—reforming our sentencing policies so that scarce resources are applied in the most effective ways, supporting evidence-based alternatives to incarceration that mitigate risks to the general public and reduce recidivism, and ensuring access to evidence-based treatment models—including MAT for the treatment of opioid use disorders—and recovery support . At the Federal level, legislative and policy changes have resulted in more just sentencing, ensuring that the most violent criminals serve sentences of appropriate length and allowing low-level, non-violent drug offenders to repay their debt to society in less costly methods that also allow them to access treatment and supportive services . At the state level, justice reinvestment principles have led state leadership to rely on data about their own costs and outcomes to pass legislation and expand alterna- tives to incarceration . In the future, by fully implementing these policies, non-violent drug offenders will be diverted away from jails and prisons and toward community-based solutions that allow them to be held accountable while also rejoining their families and communities . One way the justice system can prepare people to succeed is by offering evidence-based treatment while individuals are incarcerated or under community supervision and helping them with treatment and recovery support for their return to the community . Facilitating connections with health insurance coverage, through either private insurance or Medicaid, is a critical step to maintaining continuity of care . A number of jurisdictions are working with criminal justice-involved people to enroll them in health care coverage, which is vital to connecting them with health care after they are no longer in custody . The Administration wants to help people find stability and success once they leave the justice system, which means helping them attain safe, stable housing; educational opportunities; and employment . A criminal record can be a barrier to attaining these important supports; policymakers should consider record expungement policies and processes that are easily understood and followed, to prevent a criminal conviction from haunting someone for decades after a crime is committed and punishment completed . The Administration’s balanced approach to international efforts are ultimately targeted at reducing drug production and trafficking, promoting alternative livelihoods, and strengthening the rule of law, ★ 2 ★